Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science

Abstract

Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.

Keywords

borderline personality disorder stigma psychological science

Borderline personality disorder (BPD) has long been stigmatized in academic work, clinical practice, and the broader mental-health discourse. Although most efforts to assess and address this stigmatization have focused on mental-health clinicians, researchers commonly perpetuate stigma in the scientific literature. A recent example highlights the need for efforts to improve education and research practices with regard to BPD. In March 2020, Personality and Individual Differences published an article online titled “Testing the Hot-Crazy Matrix: Borderline Personality Traits in Attractive Women and Wealthy Low Attractive Men Are Relatively Favoured by the Opposite Sex” (Blanchard et al., 2021). In brief, this work used an Internet-derived “theory” called the “hot-crazy matrix” that postulates first that all women are “at least a 4 crazy” on a 10-point scale and that, as a woman’s “hotness” increases, so does her “crazy.” A woman must be attractive but not too attractive. At the “right” attraction level, a man can tolerate some level of apparent crazy in a woman. To assess how crazy interacts with hotness to influence men’s dating preferences, Blanchard et al. (2021) substituted “BPD traits” for “crazy.” A critique of this article is available elsewhere (Olino et al., 2020), but this work is not alone in its use of pejorative, sexist language to describe people with BPD.

Negative biases and connotations of BPD unfortunately remain a consistent theme across decades of clinical lore, written work, empirical research, and public sentiment. As a group of concerned scientists who study BPD and related processes, we encourage ourselves and the field to advance beyond pejorative, stigmatizing understandings of BPD. In this article, we provide a brief overview of BPD and the history of the diagnosis, discuss how BPD has been stigmatized with a focus on peer-reviewed psychological research and other academic texts, describe the gendered nature of this stigma, and explicate its consequences. Finally, we outline recommendations for addressing stigma in research and publication processes.

Borderline Personality Disorder: History, Negative Attitudes, and Stigma

Given its prevalence in the general population (1%–2%; Lenzenweger et al., 2007) and in clinical settings (as high as 22.6%; Korzekwa et al., 2008), most people are likely to know someone with BPD, and most clinicians will treat many people with BPD. Likewise, many researchers will include people with BPD in their studies, whether or not the diagnosis is actually assessed or recognized. The disorder manifests as a pervasive pattern of instability in behavior, mood, identity, and relationships (American Psychiatric Association [APA], 2022). People with BPD use mental-health care more frequently than people with other mental illnesses (Paris & Zweig-Frank, 2001), make an average of 3.4 lifetime suicide attempts (Soloff et al., 1994), and die by suicide at high rates (10%; Black et al., 2004; Oldham, 2006; Paris & Zweig-Frank, 2001). The disorder is associated with significant distress and impairment yet has a hopeful course (Choi-Kain et al., 2020) and effective treatment options (Choi-Kain et al., 2017).

The diagnosis of BPD has been heavily stigmatized, meaning that it has come to serve as a marker of socially undesirable traits or behaviors. For BPD and other mental illnesses, this stigmatization occurs at several levels, including self-stigma (internalized stigma related to one’s mental-health difficulties), public stigma (stereotypes and consequent discriminatory behaviors endorsed by society at large), and structural stigma (how institutional policies intentionally or unintentionally lead to adverse consequences for people with mental illness; see Corrigan & Bink, 2016). We touch on each of these levels of stigma in reviewing the history of BPD’s stigmatization.

Stigma toward BPD is especially longstanding and pervasive across clinical and research contexts (Juurlink et al., 2019; McKenzie et al., 2021; Nehls, 1998 Servais & Saunders, 2007). This is likely due in part to the history of the diagnostic label. The term “border line” was originally intended to be descriptive—connoting the disorder’s existence at the edge, or border, of psychosis and neurosis (Knight, 1953; Stern, 1938). The diagnosis quickly evolved to mark patients deemed “untreatable” (Knight, 1953) and was wielded as a pejorative marker or literal stigma, primarily against women who were considered “difficult” (Stern, 1938; Stone, 1977) or “problematic” (see Gunderson, 2001).¹ Its inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) catalyzed research efforts and the development of clinical interventions. However, BPD remains understudied compared with other psychological disorders (Zimmerman & Gazarian, 2014). Moreover, the diagnostic criteria for BPD have not changed in the more than 30 years since the DSM-III-R (APA, 1987) despite significant research and treatment advances and substantive changes to many other DSM diagnoses. This reflects that evolving knowledge about BPD has not been well integrated in the nomenclature.

BPD is highly stigmatized among mental-health professionals, perhaps more so than other disorders (e.g., Bodner et al., 2011; Deans & Meocevic, 2006; Dickens et al., 2016; Juurlink et al., 2019; McKenzie et al., 2021; Nehls, 1998; Servais & Saunders, 2007). However, one study found that negative attitudes have improved over the past 15 years (Day et al., 2018). Clinicians across disciplines commonly express less sympathy, empathy, and optimism about, and more hostility toward, patients with BPD than those with other disorders (Brody & Farber, 1996; Deans & Meocevic, 2006; Dickens et al., 2016; Fraser & Gallop, 1993; Holmqvist, 2000; Lam et al., 2016; Markham & Trower, 2003; McKenzie et al., 2021; Servais & Saunders, 2007). Common descriptors of people with BPD include “manipulative,” “difficult,” “attention seeking,” “undesirable,” and “dangerous” (Deans & Meocevic, 2006; Gallop & Wynn, 1987; Nehls, 1998; Servais & Saunders, 2007; Stone et al., 1987; Woollaston & Hixenbaugh, 2008). These attitudes likely foster discrimination and contribute to poor treatment outcomes (see Aviram et al., 2006; Rüsch et al., 2008). For example, clinicians self-report that they are less likely to engage in helpful behaviors when working with people with BPD compared with other disorders (Forsyth, 2007) and that they are more likely to use “overly custodial interventions” that deprive patients of their autonomy (e.g., lengthy hospitalizations, frequent use of mental-health legislation) for people with BPD (Krawitz & Batcheler, 2006). Moreover, they are more likely to avoid treating patients with BPD entirely (Black et al., 2011; Markham, 2003; Servais & Saunders, 2007; Westwood & Baker, 2010). People with BPD commonly report experiences of discrimination or feeling that they are not being respected or taken seriously by clinicians (Juurlink et al., 2019; Lawn & McMahon, 2015). Some research has identified that clinician attitudes about BPD can be modified with training (e.g., Keuroghlian et al., 2016; Masland et al., 2018; Shanks et al., 2011), but to our knowledge no work has addressed the modification of these attitudes in other spheres, including research and editorial processes.

Negative attitudes about BPD are also pervasive outside of clinical contexts (e.g., among police; Martin & Thomas, 2015; in employment settings; Juurlink et al., 2019; in the press; Bowen, 2019). As clinicians, we caution our patients to be careful about how they search for information online or in print resources labeled as “self-help” because such resources commonly include stigmatizing and/or equivocal content. Likewise, negative and/or inaccurate depictions in film and television (e.g., Fatal Attraction) result from and advance a public narrative of BPD as nefarious, manipulative, and dangerous, which harms people with BPD in their interactions with others. Despite recent public acknowledgments by well-known figures of their experiences with BPD (e.g., Carey, 2011; Carollo, 2011; Todd, 2021), much education is still needed to rectify misunderstandings about the disorder. Indeed, one study found that participants were more likely to label vignettes describing BPD symptoms with depression or anxiety than BPD, showing little community understanding of this disorder (Furnham et al., 2015).

Often the discourse on BPD’s stigmatization stops here, with the message that clinicians and the general public endorse and perpetuate misguided negative attitudes about people with the disorder. Yet these discussions ignore how researchers and scientific literature create and further entrench these negative attitudes. Mental-health professionals must reckon with how they may cause harm to the very people they seek to help, but so too must researchers across subdisciplines, starting with clinical science and psychiatry, by critically examining how our methods and language contribute to stigmatizing discourse.

Stigma in the Research Literature

Beyond the specific research article that catalyzed the current article, pejorative terms and attitudes around BPD permeate academic work. One particularly common example in academia is the ascription of negative intentions to people with BPD. For example, peer-reviewed articles frequently ascribe manipulative intent to people with BPD (e.g., Allen & Whitson, 2004; Bailey & Shriver, 1999; Goodman et al., 2009; Harvey & Watters, 1998; Kush, 1995; Láng, 2015; Lansky & Rudnick, 1987; McEnany & Tescher, 1985; McGlashan, 1983; Rowe, 1984; Schweitzer, 2015). Measuring manipulation, or the act of “deliberately influencing or controlling the behavior of others to one’s own advantage by using charm, persuasion, seduction, deceit, guilt induction, or coercion” (Hamilton et al., 1986, p. 191), requires determining the individual’s intent and goals, yet these constructs are rarely explicitly measured in BPD research.

The frequent use of the term “manipulation” in reference to people with BPD and their symptoms is puzzling given the findings of empirical work. Although several studies have shown that health-care providers perceive people with BPD to be manipulative (Deans & Meocevic, 2006; Stroud & Parsons, 2013; Woollaston & Hixenbaugh, 2008), evidence suggesting that people with BPD actually intend to manipulate others is lacking. Studies have presented mixed evidence with respect to specific manipulative behaviors, namely sexual coercion (Centifanti et al., 2016; Khan et al., 2017), with some suggesting that people with BPD are less likely to “use charm, grace or sex appeal to achieve something” (Mandal & Kocur, 2013). Recent work supports the idea that the fear of abandonment may contribute to harmful sexual compliance among women rather than manipulation (M. Willis & Nelson-Gray, 2017). Another study labeled specific types of interpersonal behaviors often expressed by people with BPD (e.g., begging, threatening to end relationships) manipulative but did not evaluate the intention motivating those behaviors (Mandal & Kocur, 2013).

Given that sensitivity to perceived rejection and interpersonal conflict is a hallmark of BPD (Foxhall et al., 2019), behaviors perceived as manipulative may reflect direct consequences of dysregulated emotions and efforts to alleviate distress rather than intentional manipulation. All people engage in behaviors that could be called “manipulative” to meet their needs in their social environments, including alleviating distress. These behaviors are typically those that have been previously reinforced by virtue of being effective. Notably, for many people with BPD, engaging in extreme behavior patterns may have been the only effective means to have their needs met in the invalidating, chaotic, or neglectful environments common in their early lives (Fossati et al., 1999; Laporte et al., 2011). Moreover, it is possible that the labile presentation of BPD symptoms leads people to assume that the variability in their presence over time is due to an intentional shift over which individuals with BPD have personal control (Markham & Trower, 2003). However, researchers interested in BPD are aware that this instability has a variety of known causes outside of one’s control (e.g., emotion dysregulation, hormonal changes; Peters & Eisenlohr-Moul, 2019).

In addition, people with BPD are frequently identified as “attention-seeking” in academic texts (e.g., Bandelow et al., 2010; Butler et al., 2002; Fossati et al., 2016; Gunderson, 1996). For example, Bandelow and colleagues (2010) suggested that people with BPD often wear attention-seeking, “provocative” clothing or seek attention by choosing artistic careers. We are not aware of any empirical literature that suggests BPD is associated with particular types of clothing or particular intentions regarding clothing choices. Further, despite routine descriptions of people with BPD as attention-seeking, minimal research has tested this construct in relation to the disorder. One study suggested that people with BPD are elevated in attention-seeking because they exhibited greater endorsement of the belief that “people will pay attention only if I act in extreme ways” than those with other personality disorders (Butler et al., 2002). However, holding the belief that acting in extreme ways will get attention does not assess the tendency to engage in attention-seeking behavior explicitly or the motivation for such behavior. Furthermore, such a belief may be accurate in the abusive, invalidating, or neglectful environments from which people with BPD so commonly originate (e.g., Fossati et al., 1999; Golier et al., 2003; Laporte et al., 2011; Linehan, 1993).

BPD symptoms themselves, especially self-injury, suicide attempts, and frantic efforts to avoid abandonment, are often pejoratively reduced to attention-seeking. Although nonsuicidal self-injury (NSSI) is prevalent for people in the general community (approximately 5.5% of adults and up to 17.2% of adolescents; Swannell et al., 2014), it is extremely common (90%–95%) in BPD (see Reichl & Kaess, 2021). Clinical science suggests that motives for this behavior are very rarely to manipulate and more likely include expressing anger, relieving tension or unpleasant feelings, punishing oneself, generating normal feelings, and distracting oneself (Brown et al., 2002; Hooley & Franklin, 2018; Kleindienst et al., 2008, Taylor et al., 2018). Even when a person with BPD reportedly seeks attention with unhealthy strategies, it is important to consider that people with BPD experience significant distress and emotion dysregulation (Gratz et al., 2015). These behaviors may therefore reflect reinforcing feedback loops (i.e., positive and negative reinforcement), attempts to meet one’s needs, or attempts to regulate emotions in the absence of other strategies (see Hooley & Franklin, 2018). Thus, pejoratively reducing BPD symptoms to attention-seeking overlooks more likely reasons for the behavior, which are well studied and thoughtfully considered in the functional assessment of behaviors in other psychological conditions (e.g., substance use; Bresin & Mekawi, 2019). Attributing manipulative or attention-seeking intent to BPD symptoms, particularly NSSI, may also have differential impacts for women, as well as sexual- and gender-minority individuals, given that it is a more common behavior for these populations than for men, heterosexuals, and/or cisgender people (Bresin & Schoenleber, 2015; Liu et al., 2019).

Taken together, little to no evidence exists to support commonly used pejorative assumptions regarding the intentions of people with BPD despite their propagation throughout academic texts. Unfortunately, the belief that people with BPD are manipulative or attention-seeking has also reached proposals for diagnostic nosology: The DSM-5 Alternative Model of Personality Disorders (AMPD; APA, 2013) treats “manipulativeness,” “attention seeking,” and “deceitfulness” as lower-order antagonism traits that may characterize BPD and other personality pathology. More broadly, many of the trait labels in the AMPD are pejorative prima facie and, if not paired with careful explanation, have the potential to further embed stigma into future nosology. This would likely have negative cascading consequences for people with BPD.

The enduring misapplication of these terms to BPD has also intersected with a broader culture that questions the credibility of distress, particularly when it pertains to women and sexual-assault survivors. For example, Engle and O’Donohue (2012) argued, without supporting data, that people with BPD are likely to make false allegations of sexual assault partly as a result of manipulativeness and attention-seeking. Another study (Bailey & Shriver, 1999) examined “alternative explanations” for why childhood sexual abuse is commonly reported by people with BPD, noting that “BPD patients are frequently manipulative, and thus may be more likely than other patients to fabricate a history of sexual abuse in order to gain sympathy or escape responsibility” (p. 47). This study is more than 20 years old, and it is rare to find rhetoric that so explicitly questions the credibility of sexual-assault survivors’ experiences in more recent academic work. However, in our collective clinical experience, we have found that these harmful ideas continue to thrive. Moreover, older texts may have enduring effects in propagating harmful societal and legal rhetoric that sexual-assault survivors with BPD still feel today. The myth that sexual-assault allegations are often false is commonly endorsed (McGee et al., 2011), and police are especially likely to question the credibility of people reporting sexual assault when they have a mental illness (O’Neal, 2019). Pejorative, victim-blaming ideology within academia may contribute to a harmful health-care context for people with BPD in which their traumatic experiences are automatically disbelieved and their intentions maligned. This ideology exacerbates mental-health difficulties and reinforces the invalidating early experiences that often contribute to BPD (e.g., Crowell et al., 2009; Linehan, 1993).

The Gendered Nature of BPD Stigma

The stigmatization of BPD has disproportionately affected women with the label, even before it was a formal diagnosis (Stone, 1977). Negative attitudes about BPD live at the intersection of sexist attitudes toward women more broadly and negative attitudes toward emotionality and mental illness (see Becker, 1997). Messages from media, public discourse, and clinical and academic settings suggest a woman’s physical attractiveness, sexuality, and mental illness are intertwined. For example, in a memoir published by a physician about his marriage to a woman with BPD, the book description states that “he can’t understand how such a beautiful, sexy young woman would want to kill herself” (Walker, 2008). Here, the implication is that sexy and attractive women have no reason to want to kill themselves. Despite the glaring misconceptions and harmful depictions of BPD outlined even in just the book’s description, it received positive reviews. These sexualized ideas about BPD do harm in clinical settings. Although anecdotal, the current authors recall clinical supervisors during their training describing a physical profile of “borderlines” as thin and attractive. This rhetoric serves to stigmatize women with BPD and make it difficult for women to seek and receive validating and effective mental-health support. Even more concerning is the fact that these deeply sexist and stigmatizing ideas have been perpetuated in scientific research, as demonstrated in the article that spurred this critical commentary (Blanchard et al., 2021) and its depiction of “hot, crazy” women.

Gendered and sexualized ideas about BPD are also likely to harm men. Epidemiological research (which is notably limited by the use of a gender binary) suggests that prevalence rates of BPD in men and women are roughly equal in the community (e.g., Lenzenweger et al., 2007; Torgersen et al., 2001). Studies in clinical populations, albeit somewhat dated, have similarly suggested a lack of prevalence differences by gender (Carter et al., 1999; Golomb et al., 1995; Sansone & Sansone, 2011) or that personality disorders in general may be more common in men (Grilo, 2002; Grilo et al., 1996, 2002; Jackson et al., 1991). However, the disorder is disproportionately diagnosed in women (APA, 2022), and women with a BPD diagnosis are more likely to receive psychiatric and/or psychological treatment (Dehlbom et al., 2022). This may be due to sampling bias (Skodol & Bender, 2003) and a number of clinician and assessment biases (Crosby & Sprock, 2004). Men with BPD often present with more antisocial and narcissistic traits, whereas women present with more depressive, anxious, and somatic symptoms (Silberschmidt et al., 2015). These differences may evoke differential diagnostic responses from clinicians. Feminized views of BPD may also discourage men with BPD from seeking help.

Differences between general prevalence and diagnostic rates may also be due in part to a glaring problem with our science: Most BPD studies have used almost exclusively White female samples, which perpetuates the myth that BPD is a “women’s disorder” and neglects potential differences across the gender spectrum. Most BPD-treatment clinical trials have been conducted exclusively with women with BPD or are populated mostly by women (see Cristea et al., 2017). Few studies to our knowledge have examined whether BPD treatment outcomes vary by gender, and it is unclear whether BPD treatments work as well or the same for individuals who are not cisgender women. There is also a lack of representation of sexuality in BPD research. Although people with BPD are more likely to identify as LGBTQ than those without BPD (Reich & Zanarini, 2008), most research examining relationship processes in people with BPD and their intimate partners has been conducted in exclusively heterosexual samples in which the women have BPD (e.g., Bouchard et al., 2009; de Montigny-Malenfant et al., 2013; Miano et al., 2017). Consequently, considerably less is known regarding how BPD processes may influence the relationships of people identifying as LGBTQ and/or male.

Words such as “manipulative” and “attention-seeking” are easy to single out because they are clearly pejorative. However, it is critical to be thoughtful and precise about more subtle language choices we use to describe the symptoms and experiences of people with BPD. Subtle word choices can serve to amplify stigma, even if done unintentionally. For example, the word “dramatic” is commonly used to describe people with BPD (e.g., Brazandeh et al., 2018), as are “immature” (e.g., Brazandeh et al., 2018) and “hysterical” (Kramer et al., 2013). Other examples of problematic language choices include “flailing” (Conklin et al., 2006; Southward et al., 2018) and the choice to describe suicide attempts or statements as “gestures” (see Heilbron et al., 2010), which suggests a lack of seriousness, attention-seeking, or manipulation.

Consequences of Stigma

Stigma may be particularly harmful for people with BPD who already struggle with a high degree of shame and generally negative self-concept (Rizvi et al., 2011; Rüsch et al., 2007). They may be more susceptible to self-stigma, which is associated with both experienced public stigma and anticipated public stigma (Hing & Russell, 2017). The attribution of negative experiences to aspects of one’s identity is a key characteristic of shame (Tangney, 1995), which potentially explains associations between shame-proneness and greater self-stigma related to mental-health problems (Hasson-Ohayon et al., 2012). Thus, people with BPD are exposed to both the magnified public stigma of BPD and an escalating cycle between self-stigma and the shame they commonly experience.

Stigma also has other, more tangible consequences for these individuals. For instance, self-stigma and anticipated stigma can impede help-seeking and disclosure among people with mental illness (Corrigan, 2004; Heflinger & Hinshaw, 2010). Indeed, many people may avoid seeking treatment to avoid the label of mental illness (Corrigan & Bink, 2016), whereas lower internalized stigma is linked to seeking care (Cooper et al., 2003). Moreover, deleterious effects of stigma on help-seeking may be differentially impactful across ethnic groups (Horwitz et al., 2020; Loya et al., 2010) that are notably historically excluded in BPD research and clinical science more broadly. Importantly, disclosure about negative life events and their emotional consequences protects against longer-term emotional distress among people with BPD (Schoenleber et al., 2014), so stigma-induced barriers to disclosure may be particularly harmful.

Structural stigma likewise has concrete negative consequences for people with BPD, such as limiting access to appropriate care. Although people with BPD are overrepresented (9%) among emergency-department visitors (Pascual et al., 2007), emergency departments and other medical providers are not often trained to identify BPD or provide appropriate referrals (Cases et al., 2020). Furthermore, although evidence-based treatments for BPD are difficult to access for a range of reasons (e.g., treatment duration, cost, waiting lists; Lawn & McMahon, 2015; Tusiani-Eng & Yeomans, 2018), pervasive pejorative professional attitudes toward BPD can also interfere with access to specialized care. For instance, low treatment access is further exacerbated by a dearth of trained providers because relatively fewer trainees pursue specialized training in treatment for BPD than for other disorders (Iliakis et al., 2019; Tusiani-Eng & Yeomans, 2018). This may be due to the cost and time associated with learning BPD treatments. In addition, trainees are likely also discouraged from pursuing training because of negative connotations associated with the diagnosis that are perpetuated not just in clinical settings but also through academic texts and commentary offered by faculty and clinical supervisors.

Pejorative professional attitudes may also contribute to systemic barriers to accessing BPD diagnoses or treatment. For instance, some have asserted that several insurers in the United States will not accept BPD as a billable diagnosis or classify it as a serious mental illness (Tusiani-Eng & Yeomans, 2018). Additionally, lack of expertise in BPD and public stigma may lead clinicians to refrain from diagnosing BPD when it is present. Indeed, clinicians are often reluctant to diagnose BPD (Paris, 2007) or to disclose the diagnosis. Many patients with BPD (38% in one study; Lawn & McMahon, 2015) carry a diagnosis for years without receiving an adequate explanation for what it means. Although some may argue that diagnostic labels inherently stigmatize, when delivered appropriately, the BPD diagnosis often provides validation and relief and is identified by patients as crucial to conceptualizing their experiences (Ng et al., 2019). It is also critical for connection to appropriate treatment and forming realistic expectations (Gunderson et al., 2006).

People with BPD also face significant barriers to other forms of care, including medical interventions. Significant consequences in medical settings for people with BPD and comorbid disabilities result from the notions that people with BPD are manipulative, attention-seeking, and uncredible reporters of their experience. One research review, written to provide pain-management recommendations for medical practitioners who treat people with comorbid BPD and chronic headaches or related painful phenomena, described them as patients who manipulate, exaggerate, and distort (Saper & Lake, 2008). This type of belief is particularly concerning in light of evidence that BPD is associated with a higher prevalence of disabilities and chronic illnesses such as arthritis, diabetes, cardiovascular disease, stroke, and chronic pain conditions (Barber et al., 2020; Chen et al., 2017; El-Gabalawy et al., 2010; Sansone & Sansone, 2011), as well as higher rates of other physical-health symptoms, such as colds and coughs (Gratz et al., 2017). The exclusion of disability-informed research and widespread stigma may contribute to medical neglect and poor quality of medical care for people with BPD.

Clearly, nonpejorative, compassionate, rigorous empirical work focused on BPD and its treatment is needed. Yet the profound stigma associated with BPD may extend beyond patients themselves and may even hamper the production of such empirical work. This may be due to “courtesy stigma,” also referred to as “stigma by association,” whereby stigma accrues to an individual or community because of a connection to a stigmatized group (Goffman, 1963). Although not well studied, such stigma by proxy could also impact researchers who study stigmatized diagnoses or groups, leading to negative evaluations of BPD-related research. Research on BPD is substantially underrepresented in terms of studies funded by the National Institutes of Health (NIH; Zimmerman & Gazarian, 2014). For example, although BPD and bipolar disorder are comparably prevalent, impairing, and life-threatening, research focused on BPD has received less than 10% the amount of NIH funding relative to bipolar disorder (Zimmerman, 2015; Zimmerman & Gazarian, 2014). Pejorative attitudes toward BPD and their consequences permeate all levels of research and care, from the grant funding that informs treatment development, to treatment researchers, and the clinicians who administer treatments.

Such negative attitudes may even extend to the individuals conducting BPD research. Just as mental illness stigma hampers disclosure broadly (Corrigan et al., 2016), institutional stigma associated with BPD may inhibit those within the field from disclosing personal experience in professional contexts, thus increasing the apparent divide between people living with BPD and the researchers who study them. Lived experience of psychopathology is common for researchers and clinicians and can be in many ways a valuable asset (Victor et al., 2022). Recently, a scholar summarized a range of publications advising graduate school applicants not to disclose personal experiences of mental illness generally and speculated that “me-search,” a pejorative term referring to conducting research related to one’s own experience of illness, may have been a “kiss of death” for his research proposal (Devendorf, 2022). Indeed, it was only toward the end of her extraordinary research career that Marsha Linehan, a groundbreaking BPD researcher and developer of dialectical behavior therapy, publicly acknowledged her own personal history of mental illness (Carey, 2011). It may be harder for people with BPD to trust the science and treatments arising from a community that does not seem to include their voices, and this false dichotomy might discourage some in the field from being open about their personal experiences with BPD.

Recommendations

It is clear that negative, pejorative, and often sexist views of BPD continue to proliferate in ways that stymie research progress and further harm people with the disorder. What can be done? Moving forward, researchers, authors, reviewers, and editors in clinical psychology and other subdisciplines can take active steps to study the important topic of BPD without exacerbating its stigmatization. Likewise, those who are responsible for research training are in positions to combat stigma development during formative times.

Recommendations for researchers

Research on BPD should be grounded in robust, empirically sound theories and hypotheses that are not influenced by judgment, stereotypes, or biases. Researchers are encouraged to consider whether invocations of BPD in theories rely on actual diagnostic criteria of BPD (e.g., affective instability) or prior empirical research (e.g., findings of heightened levels of subjective experiences of shame, anger, and rejection sensitivity in BPD). If not, it is worth considering whether the theory invokes unfounded stereotypes of BPD (e.g., “people with BPD are manipulative”). This is especially important when the academic work is not challenging that idea (e.g., a study questioning whether a commonly held stereotype is actually valid) but rather stating it as a presupposition to a different hypothesis (e.g., testing a theory about a “hot/crazy” matrix with the assumption that BPD features are prototypes for the “crazy” label).

Avoid sex- and gender-related biases in theories, research design, and language. Does the framing of BPD-related work hold up if applied to more than one gender? If the language does not generalize well to men, for example, it may indicate biased ideas or language. If components of the study are explicitly gendered, is there an empirical reason for that choice, or is it based on assumptions? Consider also whether the work pathologizes behaviors that might be considered dysfunctional only in the context of some genders (e.g., having more sexual partners in women) or behavior that might represent a valid sexual orientation or gender identity (e.g., framing being bisexual or gender-fluid as identity disturbance; Eubanks-Carter & Goldfried, 2006; Rodriguez-Seijas et al., 2020). Moreover, it is readily apparent that the majority of research on BPD, from basic to applied studies, has focused almost exclusively on White women who are (or are presumed to be) heterosexual and cisgender. The inclusion of other gender identities and sexual orientations in research samples is critical for moving beyond gendered notions of BPD and helping people across the gender spectrum. When gender distributions are skewed at the conclusion of data collection, this should be recognized as a limitation, and researchers should consider whether they are adequately powered to detect gender differences. Researchers should also assess gender comprehensively (for guidelines, see Puckett et al., 2020), recognizing that even if underpowered to detect differences between groups, it is still important to allow participants to accurately describe their gender and to describe samples correctly.

Use targeted recruitment methods to broaden representation of minoritized and underrepresented populations. In addition to recommendations for including gender and sexual diversity, we urge researchers to focus on underserved populations. We know very little about differential impacts, mechanisms, treatment outcomes, and experiences of BPD for non-White populations, a problem that is not limited to BPD but persists more broadly in clinical science (Adams & Miller, 2022; Wilkins et al., 2020). This recommendation also applies to those researchers interested in stigma itself because stigma likely has significant intersectional influences.

Avoid language with a moralistic or otherwise judgmental approach to labeling behavior. As scientists, we are most accurate and clear if we frame our work in nonjudgmental, functional language that is as close to the evidence as possible. For example, regarding “manipulative” behavior, we can consider whether that label goes beyond the evidence. If we are describing someone’s repeated behavior that has a negative impact on others but do not know the intent or degree of forethought behind the behavior, surely it serves our understanding of the disorder and of psychology best to use the most precise language to operationalize what we observe. Labeling these behaviors as maladaptive, urgent, reactive, or even aggressive may be more accurate and allow for better consideration of the phenomena and its impact on others and, accordingly, lay the foundation for better science. BPD researchers may wish to draw on work from forensic psychology, in which the avoidance of inappropriate inferences about clients’ intentions is a central component (G. M. Willis, 2018).

Particular care and consideration should be given to the impact of titles and abstracts, including their impact when considered outside of the context of the full article. Although as academics our hope is always that people read the entirety of our work, we need to accept the reality that our article titles and abstracts carry particular weight given that many people will only go that far in their engagement or may not have access to full articles. If paragraphs within the article are needed to contextualize a title or abstract as not harmful or pejorative toward a vulnerable group, then we suggest rewording, even if the resulting title is less attention-grabbing. One suggestion is to write titles and abstracts with the full expectation that participants in the study, or a loved one with BPD, will read them.

Seek collaboration with people who have high levels of experience working with people with BPD, as well as people with lived experience. Interest in including service users in psychological science has increased in recent years (e.g., Brown & Jones, 2021; Jones et al., 2020, 2021; Moreno et al., 2020). It is critical that services users with BPD are included in this push. We suggest this for all academics, particularly those new to the topic of BPD. Collaborate in all aspects of work, from study design and implementation to reviewing language and framing choices. If BPD is a central component to a study, it likely improves the study to involve these voices from the beginning of the project, especially if the investigative team lacks clinical expertise and either lived experience or close contact with communities with personal experience. Researchers should also consider collaborating with professional organizations (e.g., National Education Alliance for BPD, Emotions Matter) with BPD expertise. These organizations may facilitate connections to people with lived experience and/or provide consultation to ensure that research is sensitive and nonstigmatizing.

It is important for all researchers to understand that asking an empirical question and producing scientific knowledge are not neutral actions and not inherently useful pursuits. Rather, asking helpful questions, with sensitivity and benevolence, is a characteristic component of good research. For example, one could ask how BPD and perceived attractiveness interact to influence men’s dating preferences. However, asking this question may legitimize sexist and pejorative ideas about BPD, especially if alternative hypotheses are not included. Researchers are encouraged to consider: Who is impacted by my asking this question? Does answering this question help people or advance science meaningfully? Have I ruled out alternative explanations for this finding?

Do not exclude participants on the basis of personality disorders or histories of self-injurious behaviors. If clinical science is to inform practice, this is critical given the prevalence of BPD in clinical settings. Moreover, excluding participants on the basis of personality disorders or self-harm not only risks misrepresenting the complex nature of mental illness but also sends an implicit message that people with these histories are somehow “other” or to be avoided. Likewise, it is important to assess for the presence of BPD when characterizing clinical samples in which this diagnosis is likely to be overrepresented (e.g., in research on populations with trauma histories).

Researchers who work with trainees at any level (e.g., undergraduate students, graduate students, interns, residents, fellows) should avoid perpetuating biases about BPD, and clinical researchers should ensure that training includes accurate information about BPD. In our experience, stigmatizing myths about BPD are often transmitted in training environments through both subtle and overt messaging. Careful attention to the validity and tone of discussions about BPD is warranted. Researchers should strive to use nonjudgmental and behaviorally specific language. In addition, given the prevalence of BPD, clinical researchers are extremely likely to work with people with BPD even if they attempt to exclude participants on the basis of personality disorders (a practice we do not recommend). Exposure to accurate information about BPD should be an integral component of training curricula.

Recommendations for the editorial process

Journals should provide specific guidance with respect to nonstigmatizing language around all mental-health conditions, including BPD, and instructions to peer reviewers should include reference to these guidelines. Pejorative language and ideas should be evaluated during peer review and, if not addressed through the revision process, serve as grounds for manuscript rejections. Further, if pejorative language is identified after publication, clear editorial policies should exist such that readers who identify problematic language have a way to indicate this to the editorial board for correction. In addition, although many journals provide guidance regarding the need for respectful and professional language, little clarity exists for how these guidelines are interpreted, applied, and enforced. For this reason, journals should develop training for editorial teams who oversee peer review.

People with BPD and other mental-health conditions should be consulted in the development of such policies and approaches. For journals regularly publishing content about personality disorders, creating a consulting board of people with lived experience, with compensation, may be the most ethical and appropriate way to involve these key voices in this conversation. Others have outlined useful recommendations for engaging service user participation in the mental-health system (e.g., Brown & Jones, 2021; Daya et al., 2020). In the context of BPD specifically, organizations that center people with the disorder (e.g., National Education Alliance for Borderline Personality Disorder, Emotions Matter) may be useful for connecting to people with lived experience. Because the BPD community is large and diverse, consultation should include multiple voices. These individuals could be called on to help craft language guidelines, screen policies for sensitivity, suggest research areas to spotlight, and brainstorm additional measures to eliminate stigmatization. Journals could also consider developing their own work group or board dedicated to integrating lived experience perspectives into research, as was initiated by Psychiatric Services this year.

For any article about BPD or that uses it as a phenotype, at least one reviewer should have BPD expertise, even for journals in other subdisciplines. Consideration should be given as to whether a clinical perspective may be important, even for a nonclinical article. Moreover, given the extent to which BPD is often stigmatized more so even than other mental illnesses, a broad clinical perspective may not suffice—BPD-specific expertise should be sought from researchers and/or clinicians who have a demonstrated history of nonstigmatizing practices.

Clinicians, researchers, and editors should make use of existing journal mechanisms to call attention to problematic research practices. Most journals have options to write letters to the editor (which may or may not be published) as well as commentaries on published articles. As a community of researchers, we should all help to hold ourselves and each other accountable by using these mechanisms to draw attention to stigmatizing research that makes it through the editorial process and encouraging our community to do better. Where possible, this should be done in a manner that calls the researchers and editors into the conversation as collaborators in improving the research process.

Conclusion

Many of the people with BPD in our personal lives or with whom we have worked professionally are among the most caring, bright, fun, and creative people we know. As is true for people with any psychological disorder, they deserve research dedicated to the betterment of their lives and reduction of suffering. Although psychological science has made important advances in understanding and treating BPD, the field must come to terms with a long-standing history of stigmatizing language, study framing, and research practices. Clinical psychological science and psychiatry should take the lead in correcting this history given their proximity to BPD, yet other subdisciplines also play a critical role. Many of the recommendations we have made will not only help to destigmatize BPD and BPD symptoms but also are likely to make research more robust and impactful in general. Moreover, even small changes to research practices (e.g., how a question is framed or the language used) can make an important difference. This is a call to action for us to remember the people behind the numbers. The sound production of science and its thoughtful dissemination are paramount. Although the recommendations outlined may require considerable effort to enact successfully, they are all achievable. Cultivating awareness and willingness to examine our own biases and limitations will help catalyze improvements in research and editorial processes and ensure that we meet the moral imperative to use science to promote understanding and human flourishing.

Footnotes

Acknowledgements

We thank Tom Olino and colleagues for their original commentary on the publication that catalyzed this article.

Transparency

Action Editor: June Gruber

Editor: Laura A. King

ORCID iDs

Sara R. Masland

Sarah E. Victor

Jessica R. Peters

Skye Fitzpatrick

Katherine L. Dixon-Gordon

Alexandra H. Bettis

Kellyann M. Navarre

Shireen L. Rizvi

Notes

References

Adams

L. M.

Miller

A. B.

(2022). Mechanisms of mental health disparities among minoritized groups: How well are the top journals in clinical psychology representing this work? Clinical Psychological Science, 10(3), 387–416. https://doi.org/10.1177/21677026211026979

Allen

D. M.

Whitson

(2004). Avoiding patient distortions in psychotherapy with borderline personality disorder patients. Journal of Contemporary Psychotherapy, 34(3), 211–229. https://doi.org/10.1023/B:JOCP.0000036631.41400.57

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed.).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., revised).

Aviram

R. B.

Brodsky

B. S.

Stanley

(2006). Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry, 14(5), 249–256. https://doi.org/10.1080/10673220600975121

Bailey

J. M.

Shriver

(1999). Does childhood sexual abuse cause borderline personality disorder? Journal of Sex & Marital Therapy, 25(1), 45–57. https://doi.org/10.1080/00926239908403976

Bandelow

Schmahl

Falkai

Wedekind

(2010). Borderline personality disorder: A dysregulation of the endogenous opioid system? Psychological Review, 117(2), 623–636. https://doi.org/10.1037/a0018095

Barber

T. A.

Ringwald

W. R.

Wright

A. G.

Manuck

S. B.

(2020). Borderline personality disorder traits associate with midlife cardiometabolic risk. Personality Disorders: Theory, Research, and Treatment, 11(2), 151. https://doi.org/10.1037/per0000373

10.

Becker

(1997). Through the looking glass: Women and borderline personality disorder. Routledge.

11.

Black

D. W.

Blum

Pfohl

Hale

(2004). Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders, 18, 226–239. https://doi.org/10/bmzx94

12.

Black

D. W.

Pfohl

Blum

McCormick

Allen

North

C. S.

Phillips

K. A.

Robins

Siever

Silk

K. R.

Williams

J. B. W.

Zimmerman

(2011). Attitudes toward borderline personality disorder: A survey of 706 mental health clinicians. CNS Spectrums, 16(3), 67–74. https://doi.org/10.1017/S109285291200020X

13.

Blanchard

A. E.

Dunn

T. J.

Sumich

(2021). Testing the “hot-crazy matrix:” Borderline personality traits in attractive women and wealthy low attractive men are relatively favoured by the opposite sex. Personality and Individual Differences, 169, Article 109964. https://doi.org/10/gh2p28

14.

Bodner

Cohen-Fridel

Iancu

(2011). Staff attitudes toward patients with borderline personality disorder. Comprehensive Psychiatry, 52(5), 548–555. https://doi.org/10.1016/j.comppsych.2010.10.004

15.

Bouchard

Sabourin

Lussier

Villeneuve

(2009). Relationship quality and stability in couples when one partner suffers from borderline personality disorder. Journal of Marital and Family Therapy, 35(4), 446–455. https://doi.org/10.1111/j.1752-0606.2009.00151.x

16.

Bowen

(2019). Stigma: A linguistic analysis of personality disorder in the UK popular press, 2008–2017. Journal of Psychiatric and Mental Health Nursing, 26(7–8), 244–253. https://doi.org/10.1111/jpm.12541

17.

Bresin

Mekawi

(2019). Do marijuana use motives matter? Meta-analytic associations with marijuana use frequency and problems. Addictive Behaviors, 99, Article 106102. https://doi.org/10/gf92c6

18.

Bresin

Schoenleber

(2015). Gender differences in the prevalence of nonsuicidal self-injury: A meta-analysis. Clinical Psychology Review, 38, 55–64. https://doi.org/10.1016/j.cpr.2015.02.009

19.

Brody

E. M.

Farber

B. A.

(1996). The effects of therapist experience and patient diagnosis on countertransference. Psychotherapy: Theory, Research, Practice, Training, 33(3), 372–380. https://doi.org/10.1037/0033-3204.33.3.372

20.

Brown

Jones

(2021). Service user participation within the mental health system: Deepening engagement. Psychiatric Services, 72(8), 963–965. https://doi.org/10.1176/appi.ps.202000494

21.

Brown

M. Z.

Comtois

K. A.

Linehan

M. M.

(2002). Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111(1), 198–202. https://doi.org/10.1037/0021-843X.111.1.198

22.

Butler

Brown

Beck

Grisham

(2002). Assessment of dysfunctional beliefs in borderline personality disorder. Behaviour Research and Therapy, 40(10), 1231–1240. https://doi.org/10.1016/S0005-7967(02)00031-1

23.

Carey

(2011, June 23). Expert on mental illness reveals her own fight. The New York Times. https://www.nytimes.com/2011/06/23/health/23lives.html

24.

Carollo

(2011, August 1). NFL star Brandon Marshall has borderline personality disorder. ABC News. https://abcnews.go.com/Health/miami-dolphins-wide-receiver-brandon-marshall-reveals-borderline/story?id=14204660

25.

Carter

J. D.

Clin

Joyce

P. R.

Mulder

R. T.

Sullivan

P. F.

Luty

S. E.

(1999). Gender differences in the frequency of personality disorders in depressed outpatients. Journal of Personality Disorders, 13(1), 67–74. https://doi.org/10.1521/pedi.1999.13.1.67

26.

Cases

Rapnouil

S. L.

Gallini

Arbus

Salles

(2020). Evidence of practice gaps in emergency psychiatric care for borderline personality disorder: How can this be explained? BMC Psychiatry, 20(1), Article 476. https://doi.org/10.1186/s12888-020-02892-7

27.

Centifanti

L. C. M.

Thomson

N. D.

Kwok

A. H.

(2016). Identifying the manipulative mating methods associated with psychopathic traits and BPD features. Journal of Personality Disorders, 30(6), 721–741. https://doi.org/10.1521/pedi_2015_29_225

28.

Chen

M. H.

Hsu

J. W.

Bai

Y. M.

T. P.

C. T.

Lin

W. C.

Tsai

S.-J.

Chang

W.-H.

Chen

T.-J.

Huang

K. L.

(2017). Risk of stroke among patients with borderline personality disorder: A nationwide longitudinal study. Journal of Affective Disorders, 219, 80–85. https://doi.org/10.1016/j.jad.2017.05.005

29.

Choi-Kain

L. W.

Finch

E. F.

Masland

S. R.

Jenkins

J. A.

Unruh

B. T.

(2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports, 4(1), 21–30. https://doi.org/10.1007/s40473-017-0103-z

30.

Choi-Kain

L. W.

Reich

D. B.

Masland

S. R.

Iliakis

E. A.

Ilagan

G. S.

(2020). Longitudinal course of borderline personality disorder: What every clinician needs to know. Current Treatment Options in Psychiatry, 7, 429–445.

31.

Conklin

C. Z.

Bradley

Westen

(2006). Affect regulation in borderline personality disorder. The Journal of Nervous and Mental Disease, 194(2), 69–77. https://10.1097/01.nmd.0000198138.41709.4f

32.

Cooper

A. E.

Corrigan

P. W.

Watson

A. C.

(2003). Mental illness stigma and care seeking. Journal of Nervous and Mental Disease, 191(5), 339–341. https://doi.org/10.1097/01.NMD.0000066157.47101.22

33.

Corrigan

(2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. https://doi.org/10/cpxspn

34.

Corrigan

Bink

A. B.

(2016). The stigma of mental illness. In Freedman

H. S.

(Ed.), Encyclopedia of mental health (2nd ed., pp. 230–234). Academic Press.

35.

Corrigan

P. W.

Michaels

P. J.

Powell

Bink

Sheehan

Schmidt

Apa

Al-Khouja

(2016). Who comes out with their mental illness and how does it help? Journal of Nervous & Mental Disease, 204(3), 163–168. https://doi.org/10/f8d45f

36.

Cristea

I. A.

Gentili

Cotet

C. D.

Palomba

Barbui

Cuijpers

(2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319–328. https://10.1001/jamapsychiatry.2016.4287

37.

Crosby

J. P.

Sprock

(2004). Effect of patient sex, clinician sex, and sex role on the diagnosis of antisocial personality disorder: Models of underpathologizing and overpathologizing biases. Journal of Clinical Psychology, 60, 583–604. https://doi.org/10.1002/jclp.10235

38.

Crowell

S. E.

Beauchaine

T. P.

Linehan

M. M.

(2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135(3), 495–510. https://doi.org/10.1037/a0015616

39.

Day

N. J. S.

Hunt

Cortis-Jones

Grenyer

B. F. S.

(2018). Clinician attitudes towards borderline personality disorder: A 15-year comparison. Personality and Mental Health, 12(4), 309–320. https://doi.org/10.1002/pmh.1429

40.

Daya

Hamilton

Roper

(2020). Authentic engagement: A conceptual model for welcoming diverse and challenging consumer and survivor views in mental health research, policy, and practice. International Journal of Mental Health Nursing, 29(2), 299–311. https://doi.org/10/ggf2m3

41.

Deans

Meocevic

(2006). Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder. Contemporary Nurse, 21(1), 43–49. https://doi.org/10.5172/conu.2006.21.1.43

42.

Dehlbom

Wetterborg

Lundqvist

Maurex

Dal

Dalman

Kosidou

(2022). Gender differences in the treatment of patients with borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 13(3), 277–287. https://doi.org/10.1037/per0000507

43.

de Montigny-Malenfant

Santerre

M. È.

Bouchard

Sabourin

Lazaridès

Bélanger

. (2013). Couples’ negative interaction behaviors and borderline personality disorder. The American Journal of Family Therapy, 41(3), 259–271. https://doi.org/10.1080/01926187.2012.688006

44.

Devendorf

A. R.

(2022). Is “me-search” a kiss of death in mental health research? Psychological Services, 19(1), 49–54. https://doi.org/10.1037/ser0000507

45.

Dickens

G. L.

Lamont

Gray

(2016). Mental health nurses’ attitudes, behaviour, experience and knowledge regarding adults with a diagnosis of borderline personality disorder: Systematic, integrative literature review. Journal of Clinical Nursing, 25(13–14), 1848–1875. https://doi.org/10.1111/jocn.13202

46.

El-Gabalawy

Katz

L. Y.

Sareen

(2010). Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Psychosomatic Medicine, 72(7), 641–647. https://doi.org/10.1097/PSY.0b013e3181e10c7b

47.

Engle

O’Donohue

(2012). Pathways to false allegations of sexual assault. Journal of Forensic Psychology Practice, 12(2), 97–123. https://doi.org/10.1080/15228932.2012.650071

48.

Eubanks-Carter

Goldfried

M. R.

(2006). The impact of client sexual orientation and gender on clinical judgments and diagnosis of borderline personality disorder. Journal of Clinical Psychology, 62(6), 751–770. https://doi.org/10.1002/jclp.20265

49.

Forsyth

(2007). The effects of diagnosis and non-compliance attributions on therapeutic alliance processes in adult acute psychiatric settings. Journal of Psychiatric and Mental Health Nursing, 14(1), 33–40. https://doi.org/10.1111/j.1365-2850.2007.01036.x

50.

Fossati

Madeddu

Maffei

(1999). Borderline personality disorder and childhood sexual abuse: A meta-analytic study. Journal of Personality Disorders, 13(3), 268–280. https://doi.org/10.1521/pedi.1999.13.3.268

51.

Fossati

Somma

Borroni

Maffei

Markon

Krueger

(2016). Borderline personality disorder and narcissistic personality disorder diagnoses from the perspective of the DSM-5 personality traits: A study on Italian clinical participants. Journal of Nervous and Mental Disease, 204(12), 939–949. https://doi.org/10.1097/NMD.0000000000000587

52.

Foxhall

Hamilton-Giachritsis

Button

(2019). The link between rejection sensitivity and borderline personality disorder: A systematic review and meta-analysis. The British Journal of Clinical Psychology, 58(3), 289–326. https://doi.org/10.1111/bjc.12216

53.

Fraser

Gallop

(1993). Nurses’ confirming/disconfirming responses to patients diagnosed with borderline personality disorder. Archives of Psychiatric Nursing, 7(6), 336–341. https://doi.org/10.1016/0883-9417(93)90051-W

54.

Furnham

Lee

Kolzeev

(2015). Mental health literacy and borderline personality disorder (BPD): What do the public “make” of those with BPD? Social Psychiatry and Psychiatric Epidemiology, 50(2), 317–324. https://doi.org/10.1007/s00127-014-0936-7

55.

Gallop

Wynn

(1987). The difficult inpatient: Identification and response by staff. The Canadian Journal of Psychiatry, 32(3), 211–215. https://doi.org/10.1177/070674378703200

56.

Goffman

(1963). Stigma: Notes on the management of spoiled identity. Prentice Hall.

57.

Golier

Yehuda

Bierer

Mitropoulou

New

Schmeidler

Silverman

Siever

(2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. The American Journal of Psychiatry, 160(11), 2018–2024. https://doi.org/10.1176/appi.ajp.160.11.2018

58.

Golomb

Fava

Abraham

Rosenbaum

J. F.

(1995). Gender differences in personality disorders. The American Journal of Psychiatry, 152(4), 579–582. https://doi.org/10.1176/ajp.152.4.579

59.

Goodman

Hazlett

E. A.

New

A. S.

Koenigsberg

H. W.

Siever

(2009). Quieting the affective storm of borderline personality disorder. The American Journal of Psychiatry, 166(5), 522–528. https://doi.org/10.1176/appi.ajp.2009.08121836

60.

Gratz

K. L.

Bardeen

J. R.

Levy

Dixon-Gordon

K. L.

Tull

M. T.

(2015). Mechanisms of change in an emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Behaviour Research and Therapy, 65, 29–35. https://doi.org/10.1016/j.brat.2014.12.005

61.

Gratz

K. L.

Weiss

N. H.

McDermott

M. J.

Dilillo

Messman-Moore

Tull

M. T.

(2017). Emotion dysregulation mediates the relation between borderline personality disorder symptoms and later physical health symptoms. Journal of Personality Disorders, 31(4), 433. https://doi.org/10.1521/pedi.2016.30.252

62.

Grilo

C. M.

(2002). Are there gender differences in DSM-IV personality disorders? Comprehensive Psychiatry, 43(6), 427–430.

63.

Grilo

C. M.

Anez

L. M.

McGlashan

T. H.

(2002). DSM-IV axis II comorbidity with borderline personality disorder in monolingual Hispanic psychiatric outpatients. The Journal of Nervous and Mental Disease, 190(5), 324–330.

64.

Grilo

C. M.

Becker

D. F.

Fehon

D. C.

Walker

M. L.

Edell

W. S.

McGlashan

T. H.

(1996). Gender differences in personality disorders in psychiatrically hospitalized adolescents. The American Journal of Psychiatry, 153(8), 1089–1091. https://doi.org/10.1176/ajp.153.8.1089

65.

Gunderson

J. G.

(1996). Borderline patient’s intolerance of aloneness: Insecure attachments and therapist availability. The American Journal of Psychiatry, 153(6), 752–758. https://doi.org/10.1176/ajp.153.6.752

66.

Gunderson

J. G.

(2001). Borderline personality disorder: A clinical guide. American Psychiatric Association.

67.

Gunderson

J. G.

Weinberg

Daversa

M. T.

Kueppenbender

K. D.

Zanarini

M. C.

Shea

M. T.

Skodol

A. E.

Sanislow

C. A.

Yen

Morey

L. C.

Grilo

C. M.

McGlashan

T. H.

Stout

R. L.

Dyck

(2006). Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder. American Journal of Psychiatry, 163(7), 1173–1178. https://doi.org/10.1176/ajp.2006.163.7.1173

68.

Hamilton

J. D.

Decker

Rumbaut

R. D.

(1986). The manipulative patient. American Journal of Psychotherapy, 40(2), 189–200.

69.

Harvey

S. C.

Watters

M. R.

(1998). Medical treatment and discharge planning for a patient with a borderline personality: A multidisciplinary challenge. Military Medicine, 163(2), 122–125.

70.

Hasson-Ohayon

S. E. B.

Vahab

Amiaz

Weiser

Roe

(2012). Insight into mental illness and self-stigma: The mediating role of shame proneness. Psychiatry Research, 200(2–3), 802–806. https://doi.org/10.1016/j.psychres.2012.07.038

71.

Heflinger

C. A.

Hinshaw

S. P.

(2010). Stigma in child and adolescent mental health services research: Understanding professional and institutional stigmatization of youth with mental health problems and their families. Administration and Policy in Mental Health and Mental Health Services Research, 37(1–2), 61–70. https://doi.org/10/ctz373

72.

Heilbron

Compton

J. S.

Daniel

S. S.

Goldston

D. B.

(2010). The problematic label of suicide gesture: Alternatives for clinical research and practice. Professional Psychology: Research and Practice, 41(3), 221–227. https://doi.org/10.1037/a0018712

73.

Hing

Russell

A. M.

(2017). How anticipated and experienced stigma can contribute to self-stigma: The case of problem gambling. Frontiers in Psychology, 8, Article 235. https://doi.org/10.3389/fpsyg.2017.00235

74.

Holmqvist

(2000). Staff feelings and patient diagnosis. The Canadian Journal of Psychiatry, 45(4), 349–356. https://doi.org/10.1177/070674370004500403

75.

Hooley

J. M.

Franklin

J. C.

(2018). Why do people hurt themselves? A new conceptual model of nonsuicidal self-injury. Clinical Psychological Science, 6(3), 428–451. https://doi.org/10.1177/2167702617745641

76.

Horwitz

A. G.

McGuire

Busby

D. R.

Eisenberg

Zheng

Pistorello

Albucher

Coryell

King

C. A.

(2020). Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk. Journal of Affective Disorders, 271, 123–130. https://doi.org/10/gg37jb

77.

Iliakis

E. A.

Sonley

A. K.

Ilagan

G. S.

Choi-Kain

L. W.

(2019). Treatment of borderline personality disorder: Is supply adequate to meet public health needs? Psychiatric Services, 70(9), 772–781. https://doi.org/10.1176/appi.ps.201900073

78.

Jackson

H. J.

Whiteside

H. L.

Bates

G. W.

Bell

Rudd

R. P.

Edwfards

(1991). Diagnosing personality disorders in psychiatric inpatients. Acta Psychiatrica Scandinavica, 83(3), 206–213.

79.

Jones

Atterbury

Byrne

Carras

Brown

Phalen

(2021). Lived experience, research leadership, and the transformation of mental health services: Building a researcher pipeline. Psychiatric Services, 72(5), 591–593. https://doi.org/10.1176/appi.ps.202000468

80.

Jones

Byrne

Carr

(2020). If not now, when? COVID-19, lived experience, and a moment for real change. The Lancet Psychiatry, 7(12), 1008–1009.

81.

Juurlink

T. T.

Vukadin

Stringer

Westerman

M. J.

Lamers

Anema

J. R.

Beekman

A. T. F.

Marle Hein

J. F.

(2019). Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians. PLOS ONE, 14(7), Article e0220233. https://doi.org/10.1371/journal.pone.0220233

82.

Keuroghlian

A. S.

Palmer

B. A.

Choi-Kain

L. W.

Borba

C. P.

Links

P. S.

Gunderson

J. G.

(2016). The effect of attending good psychiatric management (GPM) workshops on attitudes toward patients with borderline personality disorder. Journal of Personality Disorders, 30(4), 567–576. https://doi.org/10.1521/pedi_2015_29_206

83.

Khan

Brewer

Kim

Centifanti

L. C. M.

(2017). Students, sex, and psychopathy: Borderline and psychopathy personality traits are differently related to women and men’s use of sexual coercion, partner poaching, and promiscuity. Personality and Individual Differences, 107, 72–77. https://doi.org/10.1016/j.paid.2016.11.027

84.

Kleindienst

Bohus

Ludäscher

Limberger

M. F.

Kuenkele

Ebner-Priemer

U. W.

Chapman

A. L.

Reicherzer

Stieglitz

R.-D.

Schmahl

(2008). Motives for nonsuicidal self-injury among women with borderline personality disorder. Journal of Nervous & Mental Disease, 196(3), 230–236. https://doi.org/10.1097/nmd.0b013e3181663026

85.

Knight

R. P.

(1953). Borderline states. Bulletin of the Menninger Clinic, 17, 1–12.

86.

Korzekwa

M. I.

Dell

P. F.

Links

P. S.

Thabane

Webb

S. P.

(2008). Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Comprehensive Psychiatry, 49(4), 380–386. https://doi.org/10.1016/j.comppsych.2008.01.007

87.

Kramer

de Roten

Perry

J. C.

Despland

(2013). Beyond splitting: Observer-rated defense mechanisms in borderline personality disorder. Psychoanalytic Psychology, 30(1), 3–15. https://doi.org/10.1037/a0029463

88.

Krawitz

Batcheler

(2006). Borderline personality disorder: A pilot survey about clinician views on defensive practice. Australasian Psychiatry, 14(3), 320–322. https://doi.org/10.1080/j.1440-1665.2006.02297.x

89.

Kush

F. R.

(1995). Individualized behavior therapy programs applied to borderline personality disorder: A primer for clinicians. Journal of Contemporary Psychotherapy, 25(1), 35–47. https://doi.org/10.1007/BF02308667

90.

Lam

D. C.

Poplavskaya

E. V.

Salkovskis

P. M.

Hogg

L. I.

Panting

(2016). An experimental investigation of the impact of personality disorder diagnosis on clinicians: Can we see past the borderline? Behavioural and Cognitive Psychotherapy, 44(3), 361–373. https://doi.org/10.1017/S1352465815000351

91.

Láng

(2015). Borderline personality organization predicts Machiavellian interpersonal tactics. Personality and Individual Differences, 80, 28–31. https://doi.org/10.1016/j.paid.2015.02.022

92.

Lansky

M. R.

Rudnick

(1987). Right on the money: Disability forms and the hospitalized borderline patient. Hillside Journal of Clinical Psychiatry, 8(2), 132–143.

93.

Laporte

Paris

Guttman

Russell

(2011). Psychopathology, childhood trauma, and personality traits in patients with borderline personality disorder and their sisters. Journal of Personality Disorders, 25(4), 448–462. https://doi.org/10.1521/pedi.2011.25.4.448

94.

Lawn

McMahon

(2015). Experiences of care by Australians with a diagnosis of borderline personality disorder. Journal of Psychiatric and Mental Health Nursing, 22(7), 510–521. https://doi.org/10.1111/jpm.12226

95.

Lenzenweger

M. F.

Lane

M. C.

Loranger

A. W.

Kessler

R. C.

(2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553–564. https://doi.org/10.1016/j.biopsych.2006.09.019

96.

Linehan

(1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

97.

Liu

R. T.

Sheehan

A. E.

Walsh

R. F.

Sanzari

C. M.

Cheek

S. M.

Hernandez

E. M.

(2019). Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and meta-analysis. Clinical Psychology Review, 74, Article 101783. https://doi.org/10.1016/j.cpr.2019.101783

98.

Loya

Reddy

Hinshaw

S. P.

(2010). Mental illness stigma as a mediator of differences in Caucasian and South Asian college students’ attitudes toward psychological counseling. Journal of Counseling Psychology, 57, 484–490. https://doi.org/10/bthktv

99.

Mandal

Kocur

(2013). Psychological masculinity, femininity and tactics of manipulation in patients with borderline personality disorder. Archives of Psychiatry and Psychotherapy, 15(1), 45–53.

100.

Markham

(2003). Attitudes towards patients with a diagnosis of “borderline personality disorder”: Social rejection and dangerousness. Journal of Mental Health, 12(6), 595–612. https://doi.org/10.1080/09638230310001627955

101.

Markham

Trower

(2003). The effects of the psychiatric label “borderline personality disorder”: on nursing staff’s perceptions and causal attributions for challenging behaviours. British Journal of Clinical Psychology, 42(3), 243–256. https://doi.org/10.1348/01446650360703366

102.

Martin

Thomas

(2015). Police officers’ views of their encounters with people with personality disorder. Journal of Psychiatric and Mental Health Nursing, 22(2), 125–132. https://doi.org/10.1111/jpm.12099

103.

Masland

S. R.

Price

MacDonald

Finch

E. F.

Gunderson

J. G.

Choi-Kain

L. W.

(2018). Enduring effects of one-day training in good psychiatric management on clinician attitudes about borderline personality disorder. Journal of Nervous and Mental Disease, 206(11), 865–869. https://doi.org/10.1097/NMD.0000000000000893

104.

McEnany

G. W.

Tescher

B. E.

(1985). Contracting for care: One nursing approach to the hospitalized borderline patient. Journal of Psychosocial Nursing and Mental Health Services, 23(4), 11–18.

105.

McGee

O’Higgins

Garavan

Conroy

(2011). Rape and child sexual abuse: What beliefs persist about motives, perpetrators, and durvivors? Journal of Interpersonal Violence, 26(17), 3580–3593. https://doi.org/10.1177/0886260511403762

106.

McGlashan

T. H.

(1983). Omnipotence, helplessness, and control with the borderline patient. American Journal of Psychotherapy, 37(1), 49–61.

107.

McKenzie

Gregory

Hogg

(2021). Mental health workers’ attitudes toward individuals with a diagnosis of borderline personality disorder: A systematic literature review. Journal of Personality Disorders, 14, 70–98. https://doi.org/10.1521/pedi_2021_35_528

108.

Miano

Fertuck

E. A.

Roepke

Dziobek

(2017). Romantic relationship dysfunction in borderline personality disorder—A naturalistic approach to trustworthiness perception. Personality Disorders: Theory, Research, and Treatment, 8(3), 281–286. https://doi.org/10.1037/per0000196

109.

Moreno

Wykes

Galderisi

Nordentoft

Crossley

Jones

Cannon

Correll

C. U.

Byrne

Carr

Chen

E. Y. H.

Gorwood

Johnson

Karkkainen

Krystal

J. H.

Lee

Lieberman

Lopez-Jaramillo

Mannikko

. . . Arango

(2020). How mental health care should change as a consequence of the COVID-19 pandemic. The Lancet Psychiatry, 7(9), 813–824.

110.

Nehls

(1998). Borderline personality disorder: Gender stereotypes, stigma, and limited system of care. Issues in Mental Health Nursing, 19(2), 97–112. https://doi.org/10.1080/016128498249105

111.

F. Y. Y.

Townsend

M. L.

Miller

C. E.

Jewell

Grenyer

B. F.

(2019). The lived experience of recovery in borderline personality disorder: A qualitative study. Borderline Personality Disorder and Emotion Dysregulation, 6, Article 10. https://doi.org/10.1186/s40479-019-0107-2

112.

Oldham

J. M.

(2006). Borderline personality disorder and suicidality. The American Journal of Psychiatry, 163, 20–26. https://doi.org/10/d5d2kq

113.

Olino

T. M.

Nielsen

J. D.

Case

J. A. C.

Hayden

E. P.

Wojcieszak

Mennies

R. J.

(2020). Matters arising from Blanchard, A. E., Dunn, T. J., & Sumich, A. (2020). Borderline personality traits in attractive women and wealthy low attractive men are relatively favoured by the opposite sex. Personality and Individual Differences, 165(15), Article 110123. https://doi.org/10.1016/j.paid.2020.110123

114.

O’Neal

E. N.

(2019). “Victim is not credible:” The influence of rape culture on police perceptions of sexual assault complainants. Justice Quarterly, 36(1), 127–160. https://doi.org/10.1080/07418825.2017.1406977

115.

Paris

(2007). Why psychiatrists are reluctant to diagnose: Borderline personality disorder. Psychiatry, 4(1), 35–39.

116.

Paris

Zweig-Frank

(2001). A 27-year follow-up of patients with borderline personality disorder. Comprehensive Psychiatry, 42(6), 482–487. https://doi.org/10/fppv89

117.

Pascual

J. C.

Córcoles

Castaño

Ginés

J. M.

Gurrea

Martín-Santos

Bulbena

(2007). Hospitalization and pharmacotherapy for borderline personality disorder in a psychiatric emergency service. Psychiatric Services, 58(9), 1199–1204.

118.

Peters

J. R.

Eisenlohr-Moul

T. A.

(2019). Ovarian hormones as a source of fluctuating biological vulnerability in borderline personality disorder. Current Psychiatry Reports, 21, Article 109. https://doi.org/10.1007/s11920-019-1096-y

119.

Puckett

J. A.

Brown

N. C.

Dunn

Mustanski

Newcomb

M. E.

(2020). Perspectives from transgender and gender diverse people on how to ask about gender. LGBT Health, 7(6), 305–311.

120.

Reich

D. B.

Zanarini

M. C.

(2008). Sexual orientation and relationship choice in borderline personality disorder over ten years of prospective follow-up. Journal of Personality Disorders, 22(6), 564–572. https://doi.org/10.1521/pedi.2008.22.6.564

121.

Reichl

Kaess

(2021). Self-harm in the context of borderline personality disorder. Current Opinion in Psychology, 37, 139–144. https://doi.org/10.1016/j.copsyc.2020.12.007

122.

Rizvi

S. L.

Brown

M. Z.

Bohus

Linehan

M. M.

(2011). The role of shame in the development and treatment of borderline personality disorder. In Dearing

R. L.

Tangney

J. P.

(Eds.), Shame in the therapy hour (pp. 237–260). American Psychological Association.

123.

Rodriguez-Seijas

Morgan

T. A.

Zimmerman

(2020). Is there a bias in the diagnosis of borderline personality disorder among lesbian, gay, and bisexual patients? Assessment, 28(3), 724–738. https://doi.org/10.1177/1073191120961833

124.

Rowe

(1984). The student nurse and the borderline patient. Issues in Mental Health Nursing, 6(3-4), 311–319. https://doi.org/10.3109/01612848409140901

125.

Rüsch

Lieb

Göttler

Hermann

Schramm

Richter

Jacob

G. A.

Corrigan

P. W.

Bohus

(2007). Shame and implicit self-concept in women with borderline personality disorder. The American Journal of Psychiatry, 164(3), 500–508. https://doi.org/10.1176/ajp.2007.164.3.500

126.

Rüsch

Schiel

Corrigan

P. W.

Leihener

Jacob

G. A.

Olschewski

Lieb

Bohus

(2008). Predictors of dropout from inpatient dialectical behavior therapy among women with borderline personality disorder. Journal of Behavior Therapy and Experimental Psychiatry, 39(4), 497–503. https://doi.org/10.1016/j.jbtep.2007.11.006

127.

Sansone

R. A.

Sansone

L. A.

(2011). Gender patterns in borderline personality disorder. Innovations in Clinical Neuroscience, 8(5), 16.

128.

Saper

J. R.

Lake

A. E.

(2002). Borderline personality disorder and the chronic headache patient: Review and management recommendations. Headache: The Journal of Head and Face Pain, 42(7), 663–674. https://doi.org/10.1046/j.1526-4610.2002.02156.x

129.

Sato

(2006). Renaming schizophrenia: A Japanese perspective. World Psychiatry, 5(1), 53–55.

130.

Schoenleber

Gratz

K. L.

Messman-Moore

DiLillo

(2014). Borderline personality disorder and self-conscious emotions in response to adult unwanted sexual experiences. Journal of Personality Disorders, 28(6), 810–823. https://doi.org/10.1521/pedi_2014_28_138

131.

Schweitzer

C. L. S.

(2015). Resilience revisited: What ministers need to know about borderline personality disorder. Pastoral Psychology, 64(5), 727–749. https://doi.org/10.1007/s11089-014-0626-0

132.

Servais

L. M.

Saunders

S. M.

(2007). Clinical psychologists’ perceptions of persons with mental illness. Professional Psychology: Research and Practice, 38(2), 214–219. https://doi.org/10/ckvrsp

133.

Shanks

Pfohl

Blum

Black

D. W.

(2011). Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop. Journal of Personality Disorders, 25(6), 806–812. https://doi.org/10.1521/pedi.2011.25.6.806

134.

Silberschmidt

Lee

Zanarini

Schulz

S. C.

(2015). Gender differences in borderline personality disorder: Results from a multinational, clinical trial sample. Journal of Personality Disorders, 29(6), 828–838.

135.

Skodol

A. E.

Bender

D. S.

(2003). Why are women diagnosed borderline more than men? Psychiatric Quarterly, 74(4), 349–360.

136.

Soloff

P. H.

Lis

J. A.

Kelly

Cornelius

Ulrich

(1994). Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 8(4), 257–267. https://doi.org/10/bxvz85

137.

Southward

M. W.

Altenburger

E. M.

Moss

S. A.

Cregg

D. R.

Cheavens

J. S.

(2018). Flexible, yet firm: A model of healthy emotion regulation. Journal of Social and Clinical Psychology, 37(4), 231–251. https://doi.org/10.1521/jscp.2018.37.4.231

138.

Stern

(1938). Psychoanalytic investigation and therapy in the borderline group of neuroses. The Psychoanalytic Quarterly, 7, 467–489.

139.

Stone

M. H.

(1977). The borderline syndrome: Evolution of the term, genetic aspects, and prognosis. American Journal of Psychotherapy, 31(3), 345–365.

140.

Stone

M. H.

Stone

D. K.

Hurt

S. W.

(1987). Natural history of borderline patients treated by intensive hospitalization. Psychiatric Clinics of North America, 10(2), 185–206.

141.

Stroud

Parsons

(2013). Working with borderline personality disorder: A small-scale qualitative investigation into community psychiatric nurses’ constructs of borderline personality disorder. Personality and Mental Health, 7(3), 242–253. https://doi.org/10.1002/pmh.1214

142.

Swannell

S. V.

Martin

G. E.

Page

Hasking

St John

N. J.

(2014). Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 44(3), 273–303.

143.

Tangney

J. P.

(1995). Shame and guilt in interpersonal relationships. In Tangney

J. P.

Fischer

K. W.

(Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 114–139). Guilford Press.

144.

Taylor

P. J.

Dhingra

Dickson

J. M.

McDermott

(2018). Psychological correlates of self-harm within gay, lesbian and bisexual UK university students. Archives of Suicide Research, 24, 41–56. https://doi.org/10.1080/13811118.2018.1515136

145.

Todd

C. L.

(2021, January 27). Pete Davidson shared what it was like to finally get his BPD diagnosis. Self. https://www.self.com/story/pete-davidson-bpd-diagnosis-relief

146.

Torgersen

Kringlen

Cramer

(2001). The prevalence of personality disorders in a community sample. Archives of General Psychiatry, 58(6), 590–596. https://doi.org/10.1001/archpsyc.58.6.590

147.

Tusiani-Eng

Yeomans

(2018). Borderline personality disorder: Barriers to borderline personality disorder treatment and opportunities for advocacy. Psychiatric Clinics of North America, 41(4), 695–709. https://doi.org/10.1016/j.psc.2018.07.006

148.

Victor

S. E.

Schleider

J. L.

Ammerman

B. A.

Bradford

D. E.

Devendorf

Gunaydin

Hallion

L. S.

Kaufman

E. A.

Lewis

Stage

D. L.

(2022). Leveraging the strengths of psychologists with lived experience of mental illness. Perspectives on Psychological Science. Advance online publication. https://doi.org/10.1177/17456916211072826

149.

Walker

(2008). Siren’s dance: My marriage to a borderline: A case study. BookSurge Publishing.

150.

Westwood

Baker

(2010). Attitudes and perceptions of mental health nurses towards borderline personality disorder clients in acute mental health settings: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 17(7), 657–662. https://doi.org/10.1111/j.1365-2850.2010.01579.x

151.

Wilkins

C. H.

Schindler

S. E.

Morris

J. C.

(2020). Addressing health disparities among minority populations: Why clinical trial recruitment is not enough. JAMA Neurology, 77(9), 1063–1064. https://doi:10.1001/jamaneurol.2020.1614

152.

Willis

G. M.

(2018). Why call someone by what we don’t want them to be? The ethics of labeling in forensic/correctional psychology. Psychology, Crime & Law, 24(7), 727–743. https://doi.org/10.1080/1068316X.2017.1421640

153.

Willis

Nelson-Gray

R. O.

(2017). Borderline personality disorder traits and sexual compliance: A fear of abandonment manipulation. Personality and Individual Differences, 117, 216–220. https://doi.org/10.1016/j.paid.2017.06.012

154.

Woollaston

Hixenbaugh

(2008). “Destructive whirlwind:” Nurses’ perceptions of patients diagnosed with borderline personality disorder. Journal of Psychiatric and Mental Health Nursing, 15(9), 703–709. https://doi.org/10.1111/j.1365-2850.2008.01275.x

155.

Zimmerman

(2015). Borderline personality disorder: A disorder in search of advocacy. Journal of Nervous and Mental Disease, 203(1), 8–12. https://doi.org/10.1097/NMD.0000000000000226

156.

Zimmerman

Gazarian

(2014). Is research on borderline personality disorder underfunded by the National Institute of Health? Psychiatry Research, 220(3), 941–944. https://doi.org/10.1016/j.psychres.2014.09.021